10. Conclusion
The concept of a pre-psychotic phase of schizophrenia clearly demonstrates that psychiatrists view the symptoms of schizophrenia as being on a continuum with normal human thinking and behavioural patterns. This means that people who travel down the road towards a diagnosis of schizophrenia are likely to begin their journey within the realm of normality. The diagnosis only occurs at the point in the journey where the attention of a psychiatrist is drawn to them and observations are made that they have travelled too far from normal. This point of psychiatric interception need not be the same for everyone. There is no definitive feature on the landscape that clearly marks the boundary between normal behaviour and schizophrenic symptoms.
To illustrate the continuum from normality to schizophrenia, an analogy can be drawn with a road. Imagine a road that leads from an urban setting of tower buildings (downtown Normal), through suburbs (outer Normal), through a mixed landscape on the city fringe of suburban houses and vegetable farms (early psychosis), to pastures interspersed with bushland (schizophrenic symptoms of social/occupational dysfunction) and, eventually, by degrees, into pristine wilderness (florid psychosis). Some people go all the way down the road to the wilderness before they are intercepted psychiatrically; others only get as far as the pastures and bushland. The new plan of preventive medicine is to catch young people on the outskirts of Normal, even before they leave town.
There is a bigger picture. Globalism is a new phenomenon that is beginning to deeply affect the lives of most people on the planet. Satellite broadcasting is penetrating into remote corners of the globe, and television images have initiated most of humanity into the mass culture of consumerism. The great diversity in human cultures that once guided tribes, nations, and religious groupings in their varied approaches to life has been largely melted down into a homogenous global mind-set focussed on worship of the shopping mall and the products on sale there.
It is not at all clear what sort of brave new world we are currently constructing for ourselves, but it is likely to contain at least two features that are relevant to the problems discussed in this book. The first is that an idealised market-based approach to life is not a culture to which all humanity can happily adapt. This means that an impulse towards human diversity will continue to manifest itself at the individual level. The second is that the psychiatric profession and the pharmaceutical industry are together being positioned to play an ever-more important role in controlling the minds and behaviour of people who find it difficult to adapt to this new global culture.
In the last decades of the Soviet Union, when the communist authorities found it necessary to use psychiatry to control dissidents who could not or would not conform with their own particular brand of cultural ideology, a diagnosis of schizophrenia was found to be the most convenient method. This was because schizophrenia effectively labels non-conformists as having a serious mental disease that makes them irredeemably abnormal and potentially dangerous. Once this much is accepted about people it is relatively easy to add the corollary that it is necessary to force powerful drugs on them and imprison them in a state of permanent semi-stupor, perhaps for the rest of their lives.
To understand how Soviet psychiatrists came to be used for social control it isn’t necessary to assume that their professional ethics were corrupted. They were only doing what psychiatrists do everywhere: they were identifying and ‘alienating’ individuals who could not be fitted into the social fabric. To do this they simply followed normal diagnostic procedures. And, as I have demonstrated, the diagnostic criteria for schizophrenia can be easily made to fit people who have the kinds of social and occupational problems that you would expect of the average misfit or dissident.
The use of psychiatry for social control is caused not so much by a deficiency in the professional ethics of psychiatrists as by the prevailing cultural attitude towards dissidence and social mal-adaptation. If a society does not respect the rights of social misfits, it is a fairly normal response to complement the criminal justice system with psychiatric measures as a means of controlling them. In the Soviet Union there was very little tolerance for such people. The current trend to develop early detection and intervention programmes for budding social misfits, as detailed in the preceding chapter, indicates that our own Western democracies are developing similar levels of intolerance.
I realise that many people might agree with this argument, and yet still have misgivings about my overall position. They might share my view that the diagnostic methods used for schizophrenia cast too wide a net, and that it is apparent some people are diagnosed with the condition when they only have social problems. They might also agree that measures need to be taken to ensure that diagnoses of schizophrenia are not used either for social control or for the commercial benefit of drug companies seeking captive markets. But they might go on to argue that these concerns do not negate the fact that there is still a problem to solve with ‘real’ schizophrenics. ‘Real’ schizophrenics, they might say, are people who do have a serious mental disease and do need medical treatment.
‘Real’ schizophrenics, or perhaps the belief in ‘real’ schizophrenics, is indeed still the central problem. If a lay person who believed in the concept of ‘real’ schizophrenia were asked to describe a sufferer of the condition, the answer would probably be—to use the analogy given above—that such a person has travelled all the way down the road to the psychotic wilderness at the end. An account might be given of a relative or friend who had been observed in full psychotic flight. It might involve a sketch of a person hallucinating, deluded, talking to voices, unpredictable, and generally being irritating, embarrassing, and frightening company. The portrayal would be of a person whose behaviour had no apparent relationship to normality. This image would be proffered as prima facie evidence that ‘real’ schizophrenia does exist, and that an underlying disease of some kind is the only plausible explanation of the cause.
If a psychiatrist were listening to such a conversation he or she might take the opportunity to affirm this point of view. The psychiatrist might go on to say that ‘real’ schizophrenics are not just recognisable in this florid state at the end of the road but, to experts with psychiatric training, they are also detectable in much earlier states of deterioration. And, at this point, we might all begin to realise that the argument had gone full circle, and that the psychiatrist was asking us not to worry our lay minds about highly specialised tasks such as diagnosing schizophrenia. The implication would be that we should simply accept the status quo and trust in the judgement of experts.
But experts—all types of professional experts—simply represent the interests of their clients. One of the paradoxes in the relationship between psychiatrists and schizophrenics is that schizophrenics are rarely seen as the clients of the psychiatrists who attend to them. Far more often, a psychiatrist’s client is the state, and/or the schizophrenic’s relatives. This means that when schizophrenics are in conflict with family or authorities, which is usually what brings them to the attention of psychiatrists, their psychiatrist will be representing the interests of their opponents. This raises the question as to whether the disease model used to explain schizophrenia might be a professional service supplied by psychiatrists to ease the minds of their clients.
Relatives, friends, and authorities are usually desperate for some kind of professional advice when they form a perception that a person who has not broken the law needs to be controlled. They might be uncertain about the best method of achieving their goal, and might also feel anxious about the breach of trust and the violation of civil liberties involved. It is not hard to see that the most compelling way in which a psychiatrist can relieve these doubts is by explaining that the behaviour in need of control is caused by a disease. The schizophrenic is then controlled with powerful drugs, the psychiatrist has provided a professional service, the clients’ problems of guilt and confusion have been solved, and everyone can carry on as normal—everyone, that is, except the person diagnosed with schizophrenia. And the only reason the schizophrenic can’t be normal is because he or she has apparently developed an incurable disease. But, at least, everyone can be comforted in the belief that the best possible medical treatment has been made available.
However, what relatives, friends, and authorities are not told is that there is no scientific evidence to support the psychiatric explanation that such a person in need of control has a diseased mind. Instead, the medical explanation of schizophrenic symptoms is based on four unproven, interdependent assumptions:
- The nosological (classification) assumption that the wide variety of schizophrenic symptoms all point to a discrete, underlying ‘mental disease’;
- The aetiological (causal) assumption that the underlying cause of the symptoms is accessible to scientific investigation and will eventually be revealed;
- The diagnostic assumption that psychiatrists can use schizophrenic symptoms to accurately and uniformly detect the presence of this unknown underlying disease in individual patients, without the aid of laboratory tests; and
- The treatment assumption that neuroleptic drugs are an appropriate way of treating the symptoms, even though the cause remains unknown.
When they are examined in detail, all of these assumptions are doubtful. To begin with, schizophrenia does not fit the conventional notions of ‘disease’. Indeed, an analysis of its history reveals that it was brought into existence through a long process of compromise and professional consensus-building amongst psychiatrists. This consensus-building was so successful that schizophrenia has managed to exist in the minds of psychiatrists for more than one hundred years without any scientific verification. The ‘disease’ interpretation of schizophrenic symptoms is still an unconfirmed hypothesis that relies on faith rather than hard scientific evidence to support it.
This faith is enough to maintain the medical consensus, but it is still only considered an interim measure by psychiatrists. The quest for scientific evidence about the cause has been something of a holy grail for psychiatric researchers over the past century, and a virtual army is currently engaged on the search. But they are pursuing so many widely divergent threads of inquiry that, of necessity, most of them have to be dead-ends. Not only that, but the methods these researchers are forced to use are decidedly unscientific.
Research into the cause essentially involves taking groups of schizophrenics and looking for a common denominator that makes them different from normal people. This means, apart from anything else, that the legitimacy of the research is reliant on the accuracy of the schizophrenia diagnoses of the subjects used in the research. If the diagnoses are inaccurate, and the subjects are not all of the same type, no common denominator can be found. Similarly, the value of the research also depends on schizophrenic subjects being otherwise healthy. If they have other mental/brain diseases, as well as schizophrenia, the search for the cause of schizophrenia will be confounded.
A good reason to be sceptical about the scientific basis of this aetiological research is the inability of researchers to find groups of schizophrenic subjects that meet these requirements. The diagnostic methods used to detect schizophrenia, with no support from laboratory tests, mean that there is no certainty that all the members of a group are of the same type. Different psychiatrists at different places and different times might have decided that each member of a group has schizophrenic symptoms. But the diagnostic methods used will have been varied, highly personalised, and subjective. The symptoms identified will not necessarily be the same ones, and the degree of severity of the symptoms might vary considerably. On top of this, all the members of a schizophrenic cohort assembled for research purposes will have, of necessity, varying degrees of disturbance in their brain chemistry as a result of the neuroleptic medication used to treat their schizophrenia.
These inevitable circumstances mean that the only common denominators amongst any research group of schizophrenics are likely to be a shared stigma of having been branded as mental patients and a common history of having been treated with neuroleptic drugs. Yet despite the unsuitability of schizophrenic subjects for use in scientific research, investigations into the cause of schizophrenia cannot proceed without them. This is because their living, human forms are the only evidence that schizophrenia exists. As a result, all the claims of ‘promising’ leads that come out of this type of research—such as divergent patterns in brain waves and malformations in brain architecture—are scientifically very doubtful, at best. In most cases, these results are much better explained as artefacts of the neuroleptic drugs used for treating schizophrenia, rather than as indications of the underlying cause of schizophrenia itself.
This problem of confusing schizophrenia with the effects of schizophrenia treatment extends beyond aetiological research. Normally, schizophrenics are promptly medicated upon first diagnosis. This means that psychiatrists generally have a very narrow window of opportunity through which to observe the symptoms of never-medicated schizophrenics. Most psychiatric knowledge about the nature of schizophrenia and the behaviour of schizophrenics is derived from observing medicated schizophrenics.
Once applied, neuroleptic drugs quickly suppress the diverse and bizarre schizophrenic symptoms for which the person was diagnosed, and then replace them with the relatively homogeneous and medically comprehensible symptoms of neuroleptic intoxication and neuroleptic-induced movement disorders. These drug-induced disorders are true medical problems, and they provide the common denominators of pathology which help to persuade psychiatrists that they are treating a discrete disease entity. The drug-induced movement disorders also help to convince relatives and friends that the person is indeed seriously ill.
Very few contemporary psychiatrists attempt to treat newly diagnosed schizophrenics without drugs. Those who do, such as John Weir Perry, interpret the cause of the symptoms very differently from their drug-treating colleagues. They tend to find that ‘real’ schizophrenics—that is, people who are deluded and hallucinating and in the midst of a florid psychosis—are not diseased, but are undergoing a spiritual/mystical emergency. Perry found that when he gave these people the right sort of supportive environment they would recover completely, without medical treatment, in about six weeks.
This brings me to the point of this book, which is to provide the basis for a simple argument. This argument is that involuntary medical treatment for people with schizophrenic symptoms is wrong. It is wrong factually, because there is no scientific evidence to confirm the existence of an underlying mental disease in need of treatment; it is wrong ethically, because it violates basic human rights; and it is wrong spiritually, because it robs people of their vision of life’s meaning.
Stating this wrong is not particularly difficult; righting it is another matter, of enormous proportions. It isn’t simply a matter of stating the ‘truth’. Anyone who has taken up one side or the other of a religious debate knows that it is not possible to prove conclusively to a committed believer that something does not exist. This is particularly so when a belief is as deeply embedded in the culture as the medical explanation for schizophrenic symptoms.
Not only is the cultural belief deeply embedded, but it is constantly reinforced with skilfully directed public-relations campaigning. Vested interests such as drug companies have very good reasons to ensure that it remains deeply embedded. The worldwide market for schizophrenia drugs is now a multi-billion dollar industry.
The ethical aspect of this wrong also involves deeply embedded attitudes. Although it is fairly simple to show that involuntary treatment for schizophrenia violates basic human rights, it is far more difficult to interest human rights watchdog groups in the problem. From my own experience, I have found that presenting human rights organisations with sound arguments for why they should take action against psychiatric coercion can even do more harm than good.
This was evident recently, for instance, when I attempted to raise the issue of psychiatric coercion with the Australian Human Rights and Equal Opportunities Commission. At the time, the Commission was preparing legislative recommendations to protect the freedom of religion and belief in Australia, and was seeking advice from interested parties. Despite (or because of) my extensive submission, the problem of psychiatric coercion was ignored in the Commission’s recommendations. Even worse, to ensure that law-makers would not allow human rights to interfere with continued psychiatric coercion, a definition of ‘belief’ was provided which specifically excludes from protection any ‘beliefs which are caused by mental illness’.[1] It seems to me that my submission might have simply alerted the Commission to a perceived need to recommend protection against the very type of human rights challenge I had urged them to make.
When I questioned the recommendation with a high-ranking official, a carefully prepared response was given. I was told that the Human Rights Commission believed in the existence of mental illness, and believed that mentally ill people have two kinds of belief: those which are manifestations of mental illness, and which are not protected by articles of human rights law; and those which are not manifestations of mental illness, and which are protected by Article 18 of the ICCPR. The Human Rights Commission is apparently willing to allow psychiatrists to determine whether particular beliefs are protected or not, depending on whether they are deemed to be manifestations of mental illness. When I explained that psychiatric drug treatment did not selectively target the supposed symptoms of mental illness, leaving other thoughts and beliefs unaffected, the official had no prepared response.
It seems to me that human rights organisations in the Western democracies have become so accustomed to associating human rights problems with non-democratic political systems that they are incapable of directing their vigilance to their own backyards. As a consequence, they tend to give knee-jerk support to all the cultural values of the democratic societies from which they arose. This means turning a blind eye to the use of psychiatric coercion for social control. For the time being, therefore, the human rights arguments that have been presented in this book are most useful as rhetorical tools in public debate, rather than as legal devices to be used in law courts. Although they can be used to clearly establish the moral ascendancy of people who want to refuse forced psychiatric treatment, they do not provide—under prevailing social conditions—the means for legal redress.
The third and final aspect of the wrong that is intrinsic to involuntary treatment, and which is at the heart of this book, is the spiritual aspect. This is the wrong that is caused when a person is thwarted in an attempt to grasp some personal insight about the meaning of his or her life. The mass culture guiding the direction of the new world order largely locates the meaning of human existence in the commercial marketplace. Life is a struggle to work, and to buy, and to sell. We have families so we can rear children to do the same. Underneath the cacophony of lifestyles and choices that are endlessly available, there is little that is culturally valued that does not point in the direction of the marketplace and consumerism.
Anyone who even begins to think about the possibility of there being a deeper or alternative meaning to life is going to look a little weird to those who conform. Almost by definition, someone who believes that he or she has found some alternative meaning, through internal revelation, is mentally disordered. Perhaps a way of making sense of the road out of Normal, and of how it relates to a diagnosis of schizophrenia, is to look at it this way: a person on the outskirts of Normal, with pre-psychotic symptoms, is a young person with an inclination to look for an alternative meaning in life; someone intercepted halfway down the road, who has become socially alienated, is one who is actively seeking an alternative meaning; and someone in the midst of a florid psychosis, in the wilderness at the end of the road, is a person who thinks he or she has found an alternative meaning, through some kind of direct revelation.
This analogy will probably raise the question of ‘real’ schizophrenia once again in the minds of some readers. Anyone who has spent any time with a person in the midst of this type of ‘revelation’ at the end of the road, and who knows how extreme it can be, might find the analogy naive. This is particularly so if readers have witnessed a young person seeming to fall into psychosis quite suddenly, without any prior indication of having embarked on a spiritual quest. The quest for meaning in life might sound like a noble and worthwhile pursuit, to which everybody should have a right of access. But, to unprepared observers, florid psychosis usually appears to be a thoroughly degrading experience; and to suggest that it has redeeming qualities might seem absurd. Yet this is exactly what John Weir Perry found to be the case in regard to his patients at Diabasis. Joseph Campbell, the mythologist, also saw merit in the experience of psychosis. From his angle, this was the same mystical experience that mythological heroes undergo.
The problem for young people in our contemporary society, who stumble into it accidentally, is that they are untrained and unprepared for its rigours. This is why it degrades them. It is not so much the nature of the experience that is degrading, but the fact that people enter it without tutoring and support from experts who understand it. This is the very problem that both Laing and Perry sought to redress by setting up refuges for schizophrenics, staffed with spiritual guides who had themselves successfully negotiated the experience.
It might be that Perry exaggerated his success in using this method. Perhaps, in truth, a substantial fraction of people who enter into a spiritual/mystical emergency do not have whatever it takes to successfully emerge on the other side. Perhaps, despite the lack of scientific evidence, there is even a type of schizophrenic who has an incurable underlying disease of the mind or brain, after the fashion hypothesised by psychiatrists, who cannot possibly benefit from the assistance of spiritual guides. But, even if these possibilities are true, I am still convinced that most of the people who are diagnosed with schizophrenia, when they are floridly psychotic, do not have a disease but are in fact undergoing a spiritual/mystical emergency. Further, I am convinced that, under the right conditions, they can emerge from this psychological crisis with a deeper understanding about the meaning of their lives.
This finally brings me to the point at which I can try to describe the type of reform that I think should be undertaken in order to correct the brutality and ignorance that currently dominates the treatment of people diagnosed with schizophrenia.
The first reform necessary is to alter the diagnostic criteria so that only people who are in an acute psychological crisis—what I have been describing as florid psychosis—may be called schizophrenic. These are the people who have gone all the way to the end of the road out of Normal, and have become lost in the wilderness. People who are observed at other stages of the road, who only have social and occupational problems, should not be diagnosed with schizophrenia. Changes must be made to the diagnostic criteria so that these types of people are specifically excluded. It is a misuse of psychiatric power to justify intercepting them by claiming that they are at risk of becoming psychotic.
This is not to deny that some of them may well continue down the road to psychosis. But which ones? All car drivers are at risk of motor accidents, too. Should they all be dragged out of their cars to prevent some of them having accidents? Why should it be assumed that a person is heading for a psychological crisis simply because he or she wants to explore beyond the city limits of Normal? Pre-psychotic preventive medicine programmes for schizophrenia should be stopped dead in their tracks. They have the potential to do enormous harm to human individuality and diversity.
The second reform is concerned with the mental health system that handles people who have become floridly psychotic. When a person becomes psychotic for the first time, it is usual for them to pass fairly rapidly through a catchment system that ends in a psychiatric ward. Here the person is observed and diagnosed, and drug treatment is commenced. If the person is undergoing a spiritual/mystical emergency, the drugs begin to interfere with the continuity of the experience—as they are intended to do—and the person loses contact with the source of inner revelation. Most of the people who go through this drug-induced psychic abortion will never get the opportunity to properly reconnect with their true inner world again. If, at a later time, they once again become psychotic, their natural brain chemistry will have been altered by drugs, their self-identities will have been debased by labelling with mental disease and, as a result, their inner experiences will be clouded with doubt, confusion, and impurities.
What I have in mind to correct this problem is the addition of an extra filter to the standard procedures that are currently followed. People who develop the symptoms of florid psychosis already pass through one very important filter under the current standard practices. This is the medical filter at the point of diagnosis. One of the problems that complicates the handling of psychotic people is the existence of a number of disorders that are clearly medical in nature, with symptoms that overlap those of schizophrenia. Diagnostic conventions require psychiatrists to consider a variety of alternative complaints to ensure that a candidate-for-diagnosis does not have one of these. Under the heading of Differential Diagnosis, DSM-IV offers the following advice to diagnosticians:
A wide variety of general medical conditions can present with psychotic symptoms. Psychotic Disorder Due to a General Medical Condition, delirium, or dementia is diagnosed when there is evidence from the history, physical examination, or laboratory tests that indicates that the delusions or hallucinations are the direct physiological consequence of a general medical condition (for example, Cushing’s syndrome, brain tumor). Substance-Induced Psychotic Disorder, Substance-Induced Delirium, and Substance-Induced Persisting Dementia are distinguished from Schizophrenia by the fact that a substance (for example, a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the delusions or hallucinations. Many different types of Substance-Related Disorders may produce symptoms similar to those of Schizophrenia (for example, sustained amphetamine or cocaine use may produce delusions or hallucinations; phencyclidine may produce a mixture of positive and negative symptoms).[2]
I am proposing that the current practice of first-stop medical assessment of psychotic people should be retained. The objective of this medical assessment is to filter out people whose psychosis is caused by known diseases so they can be given the appropriate medical attention. The change of policy I am proposing comes after schizophrenia is diagnosed. At this point, instead of commencing neuroleptic drug treatment, the person should be referred on to a residential facility modelled along the lines of John Weir Perry’s Diabasis.
This drug-free residential facility would act as a second filter so that people undergoing a spiritual/mystical emergency could be distinguished from a hypothetical residue of ‘real’ schizophrenics. Here, people in the midst of psychological crisis would be given every opportunity and support to help them through what would be assumed to be (until proven otherwise) a spiritual/mystical emergency. The advice and attention of non-psychiatrists, who had themselves been through the experience, would be an important component. These arrangements need not exclude psychiatric supervision. Indeed, psychiatric supervision would probably be necessary if such a facility were to be seen as a filter attached to the mainstream mental-health catchment system.
If there were people who clearly could not benefit from this type of supportive treatment, they would form a separate group. Assessments of the members of this group would have to be made to ensure that their continuing problems were not caused by limitations in the facility, and in difficulties conforming to its rules and restrictions. Perhaps within such a hypothetical residual group the elusive ‘real’ schizophrenic, with the underlying disease, might at last be recognisable.
But the question of how to properly define this hypothetical residual group, and how to best treat them, is not something that can be sensibly guessed at here. If this second filter of a spiritual/mystical emergency refuge were to be added to the current mental health model, the one thing that is certain is that most of the people who develop florid psychoses would emerge from their psychological crisis in much better shape. As a result, there would be enormous social benefits from the creative input of those who had recovered, as well as long-term cost savings on disability pensions and government-subsidised medication.
The main obstacles that can be envisaged to running a trial of an extra filter such as this are only the obvious ones—the vested interests that stand to lose. These are the transnational drug companies, the biomedically oriented elements of the psychiatric profession, and those people and institutions that are already committed to a brave new world order of mass conformity.
[1] Human Rights and Equal Opportunity Commission, Article 18: Freedom of religion and belief, Human Rights and Equal Opportunity Commission, Sydney, July 1998, p. 27.
[2] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV), p. 283.